Portrayal of Complementary and Alternative Medicine for Cancer by Top Online News Sites

Abstract

Background:

Medical research news provided through the World Wide Web is easily accessible to the general public. Thus, it is necessary to understand how research findings released from online news sources are portrayed.

Methods:

The sample includes articles (n=205) published between January 1, 2010 and June 18, 2010 in top online news sites with competitive traffic rankings in the United States as determined by Alexa.com. Google Reader was used to find health-related news articles corresponding to the relevant news sources. Data analysis was performed using SPSS with two-tailed significance values of the χ² statistic.

Results:

A content analysis (n=205 stories) revealed that the majority of complementary and alternative medicine (CAM) modalities for cancer discussed in top online news sources are classified as nutritional therapeutics, and the cancer topic that appeared most frequently was that of prevention. General oncology was the most frequently cited cancer type that was discussed with regard to CAM. Medical journals were the most frequently cited source in CAM/cancer news articles. The majority of news stories on CAM/cancer were neutral in tone, and the relationship between tone and evidence type reported was statistically significant. Observational studies rather than randomized controlled trials were the predominant form of evidence provided for research findings.

Conclusions:

Overall, the quality of how online news sources report research findings on complementary and alternative medicine therapies for cancer is fairly high. However, certain top online media sources are more reliable and informative than others when it comes to reporting about CAM remedies for cancer.

Introduction

C omplementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”¹ Individuals who choose CAM therapy often seek ways to relieve symptoms associated with conventional treatment or advanced disease.² Use of CAM among cancer survivors is under-reported, with as many as 81% of survivors using vitamin or mineral supplements.³ Survivors of melanoma and kidney cancers are less likely to use CAM, whereas survivors of breast, ovarian, non-Hodgkin lymphoma, and brain and neurologic cancers are more likely to use it.

Although the use of CAM has increased over time, scientific research provides only limited evidence of its clinical efficacy.^4
–6 The mass media is often the main channel through which the public gains access to these research findings. Patients seek and scan information on the Internet to supplement information provided by health care providers.⁷ A review conducted by a team at the University of Florida found that although 86% of adult patients use the Internet to answer health care questions, the percentage of patients who actually consult with primary medical providers about the information is estimated to be less than 41%.⁸ More than 67% of adults diagnosed with cancer who responded to the 2003 Health Information National Trends Survey reported seeking health information on their own, and the majority of the respondents reported that they went to the Internet for health information.⁹

Due to the unregulated nature of the Internet, not all information presented is accurate, consistent, or reliable. Moreover, Internet users may not be able to critically evaluate online sources of health information, which may fail to define the absolute and relative risks and the benefits derived from prevention.¹⁰ Health-related Web searches may lead these patients to self-diagnosis and to implement treatment approaches based on limited knowledge. The information obtained may lead to ill-informed decision-making and health behavior practices, especially among ethnic minorities.¹¹ Ayers and Kronenfeld found that the more often an individual uses the Internet for health information, the more likely the person would be to his or her health behaviors.¹² Health scanning sessions on the Web may lead to cyberchondria, the unfounded escalation of concern about disease and self-diagnosis.¹³ The Microsoft Research study found that out of 11,158 Internet sessions of medical concern, 5.3% led to a query escalation.

Given that consumers frequently read online news on health without consulting their primary care provider and the possibility that online news may mislead patients who lack medical literacy about the scientific evidence of legitimate treatments,¹⁴ it is imperative to objectively evaluate the characteristics of the news provided. How medical research on CAM and cancer is reported in popular online news sources has been understudied, but fortunately online news publications create an archive of medical information that can be evaluated for quality and usefulness. The purpose of this article is to systematically characterize how news about CAM and cancer is disseminated from top online news sources with competitive traffic rankings in the United States.

Materials and Methods

Included in this analysis are all articles on the topic of CAM and cancer reported in the top 20 online news websites with U.S. traffic rankings based on 3 months of aggregated historical data as determined by Alexa.com.¹⁵ The traffic rankings are an important metric of the reach of different Internet properties. The lower the traffic ranking, the more well traveled the site. Two hundred (200) was chosen as the cut-off point for the traffic ranking (Table 1).

Table 1.

News Source by Rank, Traffic, Frequency-% of News Articles on Complementary and Alternative Medicine (CAM) and Cancer

News source	News rank	U.S. traffic rank	Frequency (%) CAM
Yahoo!	2	3	48 (23.4)
CNN	3	18	6 (2.9)
BBC	4	59	7 (3.4%)
The New York Times	5	24	5 (2.4)
Google	8	1	15 (7.3)
The Huffington Post	9	36	20 (9.8)
Microsoft Network (MSN)	10	12	28 (13.7)
Fox News	12	41	18 (8.8)
Reuters	13	141	26 (12.7)
Washington Post	16	81	3 (1.5)
Los Angeles Times	18	87	4 (2)
USA Today	20	92	7 (3.4)
WebMD^a	–	200	18 (8.8)
Total	–	–	205 (100)

Ranked #2 in health category rather than news category by Alexa.com

Statistics about traffic ranking and ranking in the specific news category for each website was also provided by Alexa.com.¹⁶ Alexa.com ranks the various news sites by comparing sites within the same category to each other, taking into account 3-month Alexa traffic rankings. Excluded from the analysis were specialized news websites, such as The Wall Street Journal and The Weather Channel, as well as news information provided by audio, blogs, message boards, podcasts, or video sharing. Twelve (12) news sites fulfilled these criteria (Table 1): Yahoo!, CNN, BBC, The New York Times, Google, The Huffington Post, Microsoft Network, Fox News, Reuters, The Washington Post, Los Angeles Times, and USA Today. Although WebMD is not ranked as one of the top 20 sites in the news category, the website was ranked #2 in the health category by Alexa.com and therefore was also included in the sample of news sources.

All health articles from relevant news outlets that appeared on the Internet for 24 weeks between January 1 and June 18, 2010 were reviewed by one of the authors (AP). The articles were accessed by using Really Simple Syndication (RSS) newsfeeds aggregated by Google Reader.¹⁷ All headlines of the articles were read for manifest, surface, or intended content, and interpretations of the articles were reviewed daily and discussed with a communications expert and the director of the National Cancer Institute's Office of Cancer Complementary and Alternative Medicine. If mature research was quoted, but the type of research from which the findings were obtained was not directly cited, the names of researchers or topic keywords were searched in PubMed to accurately categorize the article's design.

Variables

Articles that discussed CAM and cancer treatment were included in the analysis and all variables of interest were coded. Variables of interest included the following: evidence type, tone, cancer type, CAM category, cancer topic, and type of source citation.

Using an expanded version of The U.S. Preventive Task Force gradations, seven types of evidence were identified to analyze the news stories on CAM and cancer (Table 2). Type 1 was for the highest type of evidence (randomized controlled trials in peer-reviewed journals), whereas Types 5–7 demonstrate limited clinical significance.

Table 2.

Frequency of Types of Evidence, Tones, and Cancers Presented in Top News Sites and Association of Cancer with Complementary and Alternative Medicine (CAM)

Types of evidence	Types of research studies	Frequency	Percent
Type 1	Randomized controlled trials in peer-reviewed journals	15	7.3
Type 2	Randomized controlled trials (presented at scientific meetings or academic conferences)	17	8.3
Type 3	Prospective and retrospective cohort, ecological, and case–control studies (observational)	109	53.2
Type 4	Pilot studies with small sample size	7	3.4
Type 5	Limited to animal and laboratory studies	38	18.5
Type 6	Expert opinion only	11	5.4
Type 7	Articles without adequate information to identify evidence	8	3.9
Total		205	100.0

Tone of news articles on CAM and cancer
Neutral	132	64.4
Optimistic	58	28.3
Pessimistic	15	7.3
Total	205	100.0

Types of cancers reported in news articles on CAM and cancer ^a
	Frequency	Percent
Bladder	14	6.8
Breast	45	22.0
Chronic lymphocytic leukemia	2	1.0
Colon	22	10.7
Endometrial	2	1.0
General	62	30.2
Head and neck	2	1.0
Kidney	3	1.5
Leukemia	4	2.0
Lung	20	9.8
Lymphoma	1	0.5
Multiple	14	6.8
Multiple myeloma	1	0.5
Ovarian	1	0.5
Pancreas	11	5.4
Prostate	2	1.0
Skin	4	2.0
Stomach	5	2.4
Total	205	100

Bolded cancer categories are associated with >5% CAM use.

The emotional tone regarding the CAM therapy was evaluated and determined to be pessimistic, neutral, or optimistic. Stories that had balanced amounts of pessimism and optimism were coded as neutral; stories with a tone weighted negatively were coded as pessimistic, and more positive stories were coded as optimistic.

The cancer type addressed in each news article was recorded. Articles that did not refer to any specific cancer type were coded as general, and those that addressed more than one cancer type were coded as multiple.

CAM categories were classified in each news article according to the National Cancer Institute's Office of Cancer Complementary and Alternative Medicine (OCCAM)'s rubric for categorizing CAM therapies. OCCAM defines eight categories: alternative medical systems, energy therapies, exercise therapies, manipulative and body-based methods, mind–body interventions, nutritional therapeutics, biologic and pharmacologic treatments, and spiritual therapies.¹⁸ Articles that discussed CAM modalities that could be incorporated in more than one of these categories were classified as multiple. CAM modalities that could not be categorized into any of the remaining categories were defined as miscellaneous. News articles that made claims about CAM modalities causing cancer were also allocated to the miscellaneous category.

Cancer topics of each news article were determined and recorded as prevention, causality, treatment, side-effects, or survivorship. Articles that discussed more than one of these topics were classified as multiple.

All references to medical journals, pharmaceutical companies, National Cancer Institute, and/or American Society of Clinical Oncology were recorded as source citations. If an article cited more than one of these sources, it was classified as multiple. Some source citations included in the other sources category consisted of Federal Drug Administration, Universities, Association for International Cancer Research, and the Angiogenesis Foundation. If no source was cited, the article was classified as not applicable.

Statistical analysis

Data analysis was performed using SPSS Inc. version 17.0 with two-tailed significance values of the χ² statistic.

In order to ensure that 80% of the cells in the cross-tabulation analysis had expected frequencies >5, cells with the lowest expected frequencies were merged to form new categories of aggregated variables. For example, evidence types 4 and 5, as well as evidence types 6 and 7 were grouped in two separate categories for the analysis. Articles that were recorded as optimistic in tone and articles that were recorded as pessimistic in tone were placed in one category. Additionally, articles from Los Angeles Times, The New York Times, USA Today, and The Washington Post were merged together.

Pearson's χ² test was used to determine whether statistically significant differences exist between these categorical variables such as news source, CAM category, cancer topic, cancer type, type of source citation, tone, and evidence type. If the χ² test resulted in a statistically significant p-value, then the strength of the relationship was assessed using the symmetric measures for categorical analysis, including Phi, Cramer's V, and Contingency Coefficient.

Results

The number of CAM and cancer articles reported from each news source varies considerably (Table 1). Yahoo! generated the greatest number of such articles (n=48), reporting nearly 25% of CAM and cancer articles; followed by Microsoft Network (n=28), Reuters (n=26), The Huffington Post (n=20), Fox News (n=18), WebMD (n=18), and Google (n=15).

Observational research (Type 3) occurred among 53% of top online news sources (Table 2). Animal and laboratory studies, categorized as Type 5 evidence, were the next-most frequently reported research type, appearing in nearly 20% of the sample. Only 7% of the news sources reported using the criterion standard of medical evidence: randomized controlled trials that were published in peer-reviewed journals.

The majority of news articles on CAM/cancer were neutral in tone, comprising 64% of the sample (Table 2). Twenty-eight percent (28%) were optimistic and 7% were pessimistic.

General cancer was the most frequently cited type of cancer discussed with regard to CAM (Table 2). The most commonly cited specific cancer was breast, followed by colon, lung, multiple cancer types, pancreatic, leukemia, stomach, skin, bladder, kidney, endometrial, head and neck, prostate, lymphoma, multiple myeloma, and ovarian cancers.

The majority of CAM modalities for cancer were categorized as nutritional therapeutics (Fig. 1). This category includes an assortment of nutrients, non-nutrients, bioactive food components, and diets (Table 3). None of the CAM modalities for cancer reported in the 13 news sources examined over the study period of 24 weeks could be classified as energy therapies, manipulative and body-based methods, or spiritual therapies.

FIG. 1.

Frequency of complementary and alternative medicine categories for cancer in top news websites.

Table 3.

Complementary and Alternative Medicine (CAM) Modalities in Corresponding Office of Cancer Complementary and Alternative Medicine (OCCAM) Category

OCCAM category	CAM modalities referenced in top 12 news sites & WebMD
Alternative Medical Systems	Acupuncture
Exercise Therapies	Yoga, exercise
Mind–Body Interventions	Stress relief program
Nutritional Therapeutics	Lignans, fruits, bitter melon, rhubarb, red wine, dark chocolate, apigenin, soy, diet, Mediterranean diet, green tea, tea, pomegranate, coffee, blueberries, antioxidants, maple syrup, folic acid, chocolate, human α-lactalbumin, broccoli, papaya, seaweed, vegetables, garlic, selenium, omega-3, multivitamins, vitamin D, vitamin K, vitamin B6
Pharmacological & Biologic Treatments	Eribulin (sea sponge), AE-941 (shark cartilage), SRT501 (resveratrol), psilocybin, EBC-46 (drug from rainforest), white bloom extract
Miscellaneous	Cooking grilled meat with spices, sunlight, oxygen-based intestinal cleanser Claimed to “cause” cancer: coffee, soda, meat, carbohydrates, milk, salt, retinyl palmate, sugary foods, multivitamins
Multiples	Lifestyle (diet+exercise), (exercise+green tea), (vitamin D+Mediterranean diet)

Prevention was the most frequently mentioned cancer topic of all cancer news stories, accounting for 52% of them (Fig. 2). Articles on the topic of cancer prevention referenced wide-ranging CAM modalities such as lifestyle choices, vitamin supplementation (D, B6, K, multivitamins), and diet (Table 3). News stories about CAM use for treatment of cancer or the side-effects of therapy, survivorship, as well as news stories that discussed more than one of these topics were far less common. CAM modalities referenced to treat cancer included shark cartilage, sea sponge, and green tea. Eleven percent (11%) of news stories suggested CAM may ameliorate the side-effects of cancer treatment, such as nausea, fatigue, and depression. CAM modalities frequently cited to treat side-effects included yoga, acupuncture, and exercise, either alone or combined with green tea, and psilocybin, a hallucinogenic drug known as “magic mushrooms.”

FIG. 2.

Frequency of cancer topics in top 12 news websites and WebMD.

Of all 205 stories, 64% cited at least one journal article and 58% cited only medical journals (Table 4). The most frequently cited were The American Journal of Clinical Nutrition (n=23), Journal of National Cancer Institute (n=14), Cancer Epidemiology, Biomarkers, and Prevention (n=12), and Journal of the American Medical Association (n=10). Pharmaceutical companies, such as Eisai, Qbiotics Ltd., and GlaxoSmithKline, were mentioned alone only 3 times, comprising less than 2% of the sample. Some of the news articles lacked source citations, including The New York Times (n=3), The Huffington Post (n=3), Los Angeles Times (n=2), WebMD (n=2), CNN (n=1), Fox News (n=1), and The Washington Post (n=1).

Table 4.

Frequency of Source Citations in Top News Sites in Articles on Complementary and Alternative Medicine and Cancer

	Frequency	Percent
American Society of Clinical Oncology	14	6.8
Medical journals	119	58.0
American Journal of Clinical Nutrition (n=23)	–	–
Journal of National Cancer Institute (n=14)	–	–
Cancer Epidemiology, Biomarkers, and Prevention (n=12)	–	–
Journal of American Medical Association (n=10)	–	–
Miscellaneous journals (n=60)
Multiple sources^a	19	9.3
National Cancer Institute	5	2.4
Not applicable	13	6.3
Other sources	32	15.6
Pharmaceutical companies	3	1.5
Total	205	100.0

If an article cited more than one of these sources, it was classified as multiple.

Data analysis

There was no statistically significant association between news source and tone (p=0.154). Therefore, the differences in tone by news source are most likely due to chance alone. However, there were statistically significant differences of tone for articles that cite particular evidence types (p=0.000, χ²=54.853, df=4). Additionally, the symmetric measures for the χ² test are high (Phi=0.517, Cramer's V=0.517, and Contingency Coefficient=0.459), indicating that there exists a strong association between tone and evidence type.

Sixty percent (60%) of news stories based on randomized clinical trials (Type 1) and 75% of articles without adequate information to identify level of evidence (Type 7) were optimistic in tone (Table 5). Additionally, 37% of articles based on animal and laboratory studies (Type 5) were classified as optimistic. Eighty-six percent (86%) of Web articles that discussed observational research (Type 3) on CAM and cancer were neutral in tone. In addition, 45% of news stories citing an expert opinion were either optimistic or pessimistic in tone.

Table 5.

Tone According to Evidence Type and Number (%) of Articles in Top Online News Sites

		Evidence type and number (%) of articles
		1	2	3	4	5	6	7	Total
Tone	Neutral	2 (13)	6 (35)	94 (86)	2 (29)	20 (53)	6 (55)	2 (25)	132 (64)
	Optimistic	9 (60)	10 (59)	11 (10)	5 (71)	14 (37)	3 (27)	6 (75)	58 (28)
	Pessimistic	4 (27)	1 (6)	4 (4)	0 (0)	4 (11)	2 (18)	0 (0)	15 (7)
Total Number (%)		15 (7)	17 (8)	109 (53)	7 (3)	38 (19)	11 (5)	8 (4)	205 (100)

Discussion

Overall, the quality of how online news sources report research findings on complementary and alternative medicine therapies for cancer was fairly high. Only about 6% of news articles on CAM and cancer failed to provide sufficient evidence to support their claims. Additionally, the vast majority of the news articles were neutral in tone, presenting the positive aspects of the research findings as well as its shortcomings. Much like medical research news reported on front pages of newspapers,¹⁹ the majority of the reported research findings of CAM and cancer were based on observational studies that noted associations between dietary or lifestyle factors and cancer. The fact that online news reports are addressing the important role of lifestyle modification is of value, as it has been shown that nearly one third of cancer deaths can be linked to harmful behaviors such as smoking.²⁰ The fact that the majority of the discussion focused on topics such as prevention, and not treatment, perhaps reveals the critical need for more research proving the efficacy of CAM as a treatment modality for cancer.

Although observational research findings are a reasonably sufficient level of evidence to be reported to the public, online reportage on CAM and cancer would be more clinically relevant if it were based on a greater number of mature evidence-based clinical trials that have been scrutinized by peer reviewers and made accessible for verification. The finding that most of the evidence for the online reportage on CAM and cancer is based on observational research may reflect the fact that only a limited number of CAM modalities for patients with cancer have been subjected to rigorous scientific evaluation by randomized controlled trials.

This study revealed areas of concern regarding online medical news reports of CAM use and cancer. It is problematic that differences in tone by such low-evidence studies are statistically significant, especially when there are unfavorable trends in terms of evidence level and tone. The majority of news articles that provide insufficient information for the reader to search, locate, and verify the original published articles are positive in tone and thereby encourage CAM use for cancer. Also, positive animal and laboratory studies should be presented in a neutral tone if not followed by clinical trials, yet 37% of articles about evidence Type 5 were classified as optimistic.

It is interesting to note that news items citing randomized controlled trials that have been published in peer-reviewed journals also tended to be optimistic in tone (Table 5). This may be because peer-reviewed journals tend to primarily accept evidence-based positive research findings.²¹

This analysis reveals that some sources tend to be more informative and reliable than others for CAM/cancer news. Taking several factors into account, Yahoo!, The Huffington Post, and Reuters seem to be the best news sources for providing research updates on the topic of CAM for cancer. Compared to the other news sources, Yahoo! generated the greatest number of CAM and cancer articles, reported mostly on evidence Types 1–3, and covered the widest range of cancer types. The Huffington Post and Reuters also generated a greater number of articles on CAM/cancer. The Huffington Post had the greatest percentage of CAM/cancer articles describing type 1 evidence, and a large percentage of articles from Reuters were primarily about evidence Types 1–3.^22
–24 On the other hand, The Washington Post and The New York Times were the least informative when it came to reporting on CAM for cancer. These news sources generated very few articles and tended to report medical findings from evidence Types 6 and 7, which are the lowest evidence levels.

Patients scanning or seeking the Web for CAM and cancer news will find that most of the discussion revolves around prevention of breast cancer or cancer in general. A past content analysis of high-circulating U.S. “mainstream” and ethnic newspapers for the year 2003 found that cancer treatment is discussed far more than other aspects of cancer, including prevention and survivorship.²⁵ However, the majority of news articles on the Internet discussing CAM and cancer focused predominantly on prevention. There seems to be a discrepancy between the content of cancer news coverage in print newspapers and cancer news coverage about CAM that appears on the Internet.

Limitations

The study may be limited by several important factors, including the nature of the sample. Because the sample comprised online news stories with competitive traffic rankings only in the United States, results cannot be generalized to other countries or other forms of media. It may also be argued that several news sources had an insufficient number of articles to have meaningful results. A larger sample size would have allowed a more informative data analysis. It must be noted that some articles may have been inadvertently excluded due to the specific search strategy utilized. For instance, some relevant health articles may have been categorized as general news and thereby included in other RSS feeds of the news source besides those in the Health section. Additionally, findings were accrued from only 24 weeks of news coverage. This may not have been a long enough time interval to adequately evaluate the trends of each news source. Also, the results of the study are inextricably linked to the state of research released during that particular 24-week period, and therefore the results may not be applicable to the state of the news in every 24-week period.

Conclusions

Despite the fact that many patients consult the Internet daily to find information related to health concerns, a lack of experience, knowledge, medical literacy, or education may limit their ability to accurately evaluate health-related sites and the information they contain. Medical reporters and media organizations should advocate responsible medical news reporting, including mentioning evidence levels and study limitations. Ultimately, researchers and reporters must work together on improving communication of medical research news.

Footnotes

Acknowledgments

We gratefully acknowledge the guidance of Jeffrey D. White, MD, Director of the Office of Cancer Complementary and Alternative Medicine at the National Cancer Institute; and Shea Buckman, MA, Director of the Communications and Outreach Program at the Office of Cancer Complementary and Alternative Medicine.

Disclosure Statement

No competing financial interests exist.

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